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Artificial Pneumothorax Improves Radiofrequency Ablation Of Zuo et al. BMC Cancer (2021) 21:505 https://doi.org/10.1186/s12885-021-08223-7 RESEARCH ARTICLE Open Access Artificial pneumothorax improves radiofrequency ablation of pulmonary metastases of hepatocellular carcinoma close to mediastinum Taiyang Zuo1,2†, Wenli Lin1†, Fengyong Liu1,2 and Jinshun Xu1,2,3* Abstract Background: To investigate the feasibility, safety and efficacy of percutaneous radiofrequency ablation (RFA) of pulmonary metastases from hepatocellular carcinoma (HCC) contiguous with the mediastinum using the artificial pneumothorax technique. Method: A total of 40 lesions in 32 patients with pulmonary metastases from HCC contiguous with the mediastinum accepted RFA treatment from August 2014 to May 2018 via the artificial pneumothorax technique. After ablation, clinical outcomes were followed up by contrast enhanced CT. Technical success, local tumor progression (LTP), intrapulmonary distant recurrence (IDR), and adverse events were evaluated. Overall survival (OS) and local tumor progression free survival (LTPFS) were recorded for each patient. Results: The tumor size was 1.4 ± 0.6 cm in diameter. RFA procedures were all successfully performed without intra- ablative complications. Technical success was noted in 100% of the patients. Five cases of LTP and 8 cases of IDR occurred following the secondary RFA for treatment. Slight pain was reported in all patients. No major complications were observed. The 1, 2, and 3-year LTPFS rates were 90.6, 81.2, and 71.8%, and the 1, 2, and 3-year OS rates were 100, 100 and 87.5%, respectively. Conclusion: Artificial pneumothorax adjuvant RFA is a feasible, safe, and efficient method for treatment of pulmonary metastases from HCC contiguous with the mediastinum. Keywords: Lung metastasis, Artificial pneumothorax, Mediastinum, Radiofrequency ablation, Hepatocellular carcinoma Background However, the minimal invasive thermal technique re- Image-guided percutaneous local ablation has been mains challenging for treatment of pulmonary metastasis widely used for the treatment of pulmonary metastasis, abutting the mediastinum, as a result of the proximity to based on the high capability on accurate orientation of the heart or aorta. In 2007, Iguchi et al. reported that needles and real-time visualization of targets [1–5]. the primary technical effectiveness of radiofrequency ab- lation (RFA) was only 43% at 6 months postablation for * Correspondence: [email protected] treatment of 15 lung tumors contiguous with mediasti- †Taiyang Zuo and Wenli Lin contributed equally to this work. num [6]. Subsequently, studies on the efficacious im- 1 Department of Interventional Oncology, Jinan Central Hospital Affiliated to provement of RFA for treatment of lung tumors Shandong University, Jinan 250013, Shandong, China 2Department of Interventional Radiology, Department of Interventional contiguous with mediastinum were rarely reported be- Ultrasound, Chinese PLA General Hospital, Beijing 100853, Shandong, China cause of the insurmountable technique risk. Therefore, a Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Zuo et al. BMC Cancer (2021) 21:505 Page 2 of 8 safe and effective adjuvant method should be developed The exclusion criteria were: I) patients with severe to reduce the risk of puncture and ablation for improve- coagulation dysfunction including thrombocyte num- ment of RFA efficiency of lung tumor contiguous with ber < 30 × 10 [9]/L, international normalized ratio mediastinum. (INR) > 3.0, prothrombin time > 30 s, or prothrombin Artificial pneumothorax is a standard technique that activity (PTA) < 40%; II) acute infection or chronic in- serves as an effective adjuvant for the clinical ablation fection in acute phase; III) severe pulmonary hyper- of peripheral lung tumors [7, 8], which could be used tension defined as mean pulmonary artery pressure for separation between the punctured needle path and (mPAP) > 35 mmHg measured by cardiac normal tissues after gas administration into the catheterization and (or) Doppler echocardiogram; IV) pleural cavity [9]. It is suggested that the pulmonary severe pulmonary insufficiency defined as PaO2 <60 tumors could be accurately separated from medias- mmHg, with and without PaCO2 >50mmHg; and V) tinal structures during an artificial pneumothorax pro- implantation of cardiac pacemaker. cedure. In that case, thermal damage to heart, aorta, or main nerves would be controlled, and pain caused Artificial pneumothorax adjuvant RFA procedure by pleura heat could be effectively alleviated. In All patients underwent contrast enhanced CT (CECT) addition, the heat-sink effect of RFA could be reduced of the chest prior to RFA in order to evaluate the as well due to the artificial-induced space between tu- anatomic relationship between lesions and peripheral mors and vessels [10]. Therefore, this strategy could cardiovascular structures. CECT was performed using not only significantly reduce the risks of puncture the SOMATOM Force CT system (Siemens, Munich, and ablation, but also enhance RFA efficiency for Germany) with intravenous administration of Omni- complete ablation. Compared with the air administra- paque (GE Medical, USA) as a contrast agent. Before tion to form artificial pneumothorax [9], CO2 is less the procedure, patients in a supine position received common but displays good properties including high continuous electrocardiogram (ECG) monitoring and diffusion coefficient, inert reaction to RFA, and pure were hypodermically injected with 1% lidocaine. Then, gas injection without unidentified substance [11]. the puncture point and needle track were determined Therefore, we investigate the feasibility, safety and ef- by CT scan (MIYABI, Siemens, Munich, Germany). ficacy of using artificial CO2 pneumothorax in this Subsequently, the biopsy needle was penetrated into study for mediating RFA of pulmonary metastases the target in a direction away from the heart and ves- contiguous with the mediastinum. sels. When the procedure was accomplished, the bi- opsy needle was removed. Methods Thereafter, the artificial pneumothorax technique was Patients enrollment performed using a 22-G puncture needle (NPAS-100, This study was approved by the institutional ethics COOK, USA) with a blunt tip. The needle was inserted committee of our hospital, patients diagnosed with along the well-designed puncture proposal, which speci- pulmonary metastases contiguous with the mediasti- fies insertion route, depth and angle. When the needle num who underwent RFA were retrospectively inves- tip reached the edge of the pleura, the needle core was tigated at our hospital from August 2014 to May pulled out, 1–2 ml of saline was injected locally to form 2018. The target lesions of all cases were confirmed a water capsule using T-stopcock and tubes. Then, saline clinically or pathologically as hepatocellular carcin- in the tube flowed into the cavity, and the water capsule oma (HCC). “Contiguous with mediastinum” was de- disappeared gradually as the needle tip continued to be fined as the distance between metastatic lesion and inserted and reached into the pleura cavity. Then, 100– mediastinum was less than 3 mm on CT or MR 500 ml of CO2 gas was frequently administered to separ- images. ate the lung parenchyma. CT scanning was performed The inclusion criteria for this study were: I) a single individually after injection of 100, 200, 300, 400, and metastatic lesion contiguous with mediastinum in the 500 ml CO2 until the tumor was separated from the unilateral lobe of lung; II) lesion size less than 3 cm mediastinum and a feasible puncture path was in diameter; III) orthotopic HCC shown to be inactive established. without recurrence and intrahepatic metastasis as in- After the RF electrode was successfully inserted into dicated by enhance imaging after surgical and (or) the tumor based on the CT scanning assessment, percu- interventional therapy; IV) no increase in numbers of taneous RFA (Model 1500, RITA Medical System, pulmonary lesions after 1–2 months of observation; Mountain View, CA, USA) was performed at 60–70 W V) patients refuse to accept surgical resection; and for 5–12 min at a rating temperature of 90 °C. During VI) Karnofsky performance status (KPS) greater than the process, an 18-G unipolar electrode (Uniblate) was 70%. chosen (the length of the needle was 15 cm and the Zuo et al. BMC Cancer (2021) 21:505 Page 3 of 8 maximum ablation range of a single electrode was 3 × 3 definition
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